Healthcare Provider Details

I. General information

NPI: 1194761908
Provider Name (Legal Business Name): GWINNETT ENDOSCOPY CENTER, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 08/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 PHILIP BLVD SUITE B
LAWRENCEVILLE GA
30046-8745
US

IV. Provider business mailing address

550 PEACHTREE ST NE SUITE 1600
ATLANTA GA
30308-2208
US

V. Phone/Fax

Practice location:
  • Phone: 770-822-5562
  • Fax: 770-338-0510
Mailing address:
  • Phone: 404-888-7575
  • Fax: 404-885-7777

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0800X
TaxonomyEndoscopy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANA BAKER
Title or Position: ADMINISTRATOR
Credential:
Phone: 404-888-7575